While most people have heard of rhinoplasty or nose surgery, most do not know what the procedure entails once you enter the hospital operating room.

Once you are in the operating room and have spoken with the people who will take care of you during the surgery, the anesthesia will be administered. The exact type of anesthesia used will depend on the duration and complexity of the surgery about to be performed, any allergies you may have to any of the anesthesia drugs available, and the preference of the surgeon and anesthesiologist. Before any incisions are made, before any intrusive procedures begin, the nose is anesthetized with a local anesthesia either lidocaine or marcaine with epinephrine. This is used to numb the tissue, the surrounding cartilage and facial bones and further protect the patient from feeling any of the surgery. In addition, many surgeons use a diluted form of cocaine possibly mixed with epinephrine to shrink the mucous membranes inside the nose as well as to seriously reduce blood flow to the area.

There are two basic approaches to rhinoplasty and depending on the artistry and sophistication of the surgeon and the type of work required, either approach may be employed with equally indiscernible success.

1. Internal (endonasal) rhinoplasty – here the surgeon makes incisions only on the inside of the nose, opens the skin up and proceeds to do his work without making any incisions on the external facia. Internal rhinoplasty requires more skill and artistry to perform and can only be properly employed in cases where the amount of surgery being performed is minimal or at least of such a nature that all of the work can be reached from the interior of the nose.

2. External rhinoplasty or open-tip rhinoplasty means the doctor is making incisions on the outside of the nose, at the crease where the nose joins the face so that there is no discernible scarring after the procedure has been completed. Open-tip rhinoplasty is usually employed where the surgery requires more extensive removal or manipulation of the skin and cartilage tissue.

Either of these procedures can be performed utilizing a local anesthetic or a general anesthesia and can usually be completed anywhere from two to four hours again depending on the complexity of the work being performed. Using either the internal or the external incision methods, the skin and cartilage of the nose is exposed and the surgeon can then begin the artful process of sculpting the existing tissue to achieve the desired goals of the patient.

Remembering that rhinoplasty is really more art than surgery, the doctor will frequently refer to the photographs and notes he has made prior to the procedure. He will carefully check the symmetry of the shape of the nose and make sure that the changes he is making are the right ones to achieve the desired result. Very small alterations, incisions as small as a millimeter or two, can make large differences after the swelling has gone down in the overall appearance and balance of the finished look. This is the artistry of the surgeon you have selected.

When the surgeon has completed the sculpting process, he will carefully check the blood vessels in the area to see if they have been affected by the surgery, he will measure the nostril openings to see if they conform to his pre-op notes and measurements and then he will begin the process of closing up the nose. Small sutures will be used to close the incisions made during the procedure whether internal or external. These incisions are similar in size and form to the ones employed by heart surgeons when they are closing up small veins and arteries after cardiovascular surgery.

Finally, a small protective splint is placed around the nose. Your surgeon will have fitted you for the splint prior to the surgery and you will be expecting it when you awaken. After about 24 to 48 hours, on your next visit, the splint will be removed and your new nose will be ready to “face” the world. You’ll be left with some swelling, a small amount of pain and some antibiotics to ward off infection.